The nurse observes the following rhythm of a client on the telemetry unit.
Which action should be completed first?
Report the findings and anticipate a medical prescription for amiodarone
Initiate a rapid response call and increase the monitor's sensitivity
Start compressions and prepare for defibrillation
Establish unresponsiveness and check the carotid pulse
The Correct Answer is D
A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
(desired dose in mg/hr) / (concentration of medication in mg/mL) = infusion rate in mL/hr.
In this case, the desired dose is 5 mg/hr, and the concentration of medication is 125 mg in 125 mL, which simplifies to 1 mg/mL.
Therefore, the infusion rate is 5 mg/hr divided by 1 mg/mL, resulting in an infusion rate of 5 mL/hr.
Rounding to the nearest whole number, the nurse should set the IV pump to 5 mL/hr.
Correct Answer is C
Explanation
A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.
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